When Lying Hurts: Supine Hypertension with Orthostatic Hypotension in a Misdiagnosed Case of POTS

Presenter: Vaishnavi Sirekulam

Supine hypertension–orthostatic hypotension (SH-OH) can be misdiagnosed as postural orthostatic tachycardia syndrome (POTS), particularly in patients with long-standing symptoms. This case describes a 63-year-old man with a prior diagnosis of POTS presenting with severe left ventricular hypertrophy and stage IV chronic kidney disease in the setting of recurrent syncope over three decades. His symptoms were partially managed with midodrine and compression stockings, and family history was notable for sudden deaths in siblings.

Orthostatic assessment revealed SH-OH rather than POTS, with a blunted baroreflex and absence of compensatory tachycardia. Further evaluation showed persistent SH-OH on monitoring, and brain MRI demonstrated diffuse subcortical white matter changes suggestive of inherited leukoencephalopathy. Management included continuation of midodrine, compression therapy, head-of-bed elevation, and initiation of nighttime clonidine, which improved supine hypertension.

This case highlights the importance of distinguishing SH-OH from POTS, particularly in patients with atypical features and end-organ damage, and suggests consideration of underlying neurogenic or genetic etiologies when neurological findings are present.

Discordance Between Diagnosis of Hypertension Based on Manual and Automatic Sphygmomanometer Measurements in a National Survey

Presenter: Jingyi Gong

The transition from manual to automated blood pressure measurement in NHANES may influence hypertension estimates. This serial cross-sectional study analyzed 4,415 US adults from the 2017–2018 cycle, where both measurement methods were used. Hypertension was defined as systolic ≥130 mmHg, diastolic ≥80 mmHg, or prior diagnosis, and outcomes included prevalence and diagnostic reclassification.

Mean systolic blood pressure was higher with manual measurement (123.9 mmHg; 95% CI 123.0–124.9) compared to automated (122.4 mmHg; 95% CI 121.5–123.2; p=0.003), while diastolic pressure was lower with manual measurement (72.8 mmHg vs 74.2 mmHg; p<0.001). Hypertension prevalence was similar (53.5% manual vs 53.0% automated). However, 10.3% of individuals classified as hypertensive by manual measurement were reclassified as non-hypertensive with automated measurement, while 10.9% were newly classified as hypertensive.

These findings indicate that the change in measurement method leads to differences in blood pressure readings and approximately 10% reclassification of hypertension status.

ACC 2026, March 28 – 30, New Orleans, LA